Medical Imaging Overused, Driving Up Costs

Part of the explosion in medical imaging over the past two decades may be attributable to overuse, and steps need to be taken to cut back, researchers say.

Initiatives include rewriting the fee-for-service system, curbing physician self-referral practices, and creating appropriateness criteria for imaging, according to William R. Hendee of the Medical College of Wisconsin in Milwaukee and colleagues. They reported their findings online in Radiology.

Imaging services and their costs have grown at about twice the rate of other technologies in healthcare including lab procedures and pharmaceuticals, Hendee and colleagues wrote.

In addition to increasing costs, overuse also exposes the public to unnecessary radiation.

In August 2009, the American Board of Radiology Foundation held a summit on medical imaging to discuss some of these problems. Delegates outlined key influential factors, as well as steps to mitigate them.

A large driver of overuse, they wrote, is the current fee-for-service program, in which costs are reimbursed on a per-procedure basis, yielding more revenue for the physician and the institution. Re-aligning the system so that it rewards evidence-based care would be a better alternative, they said.

Another is the practice of self-referral, in which the referring physician is also the service provider. Doing so is a conflict of interest, they wrote, and managing the practice would be beneficial.

The practice of defensive medicine also contributes to the problem, as does patient demand for imaging studies that they've read or heard about.

In order to remedy these issues, Hendee and colleagues called for a national effort to develop evidence-based appropriateness criteria for imaging, so that physicians can make greater use of practice guidelines in requesting and conducting imaging studies.

They also called for better education all around, for referring physicians and patients alike, on the "merits and limitations of various imaging studies for patients with specific signs and symptoms."

Physicians should also have their patients describe the imaging studies they've previously had done, as not to duplicate work that's already been done. Greater sharing with electronic records could facilitate that, they said.

They added that there's also a need for accreditation of imaging facilities.

While much of this responsibility falls on physicians, radiologists have a role to play too, Hendee and colleagues wrote.

"Often, they fail to review requested examinations for appropriateness before they are conducted or to consult with referring physicians about procedures that are being requested," they wrote.

Many, however, prefer the role of "consultant" rather than "gatekeeper," and few would have time for such a role. Nor do they typically have sufficient information about the patient.

Still, Hendee and colleagues said it "would be appropriate" for radiologists to approve certain studies before they are conducted, including expensive high-tech studies.

Since many factors contribute to overuse, the radiology community cannot "heal itself," they wrote.

They called for collaboration with their "physics and oncology colleagues, referring physicians, healthcare service payers, patient and public interest groups, and imaging equipment vendors."